67 
Techniques for Cleft Lip Repair
David Drake, Serryth Colbert
KEY POINTS
• The objectives of cleft lip repair are to reestablish an
anatomic and functional balance between the soft tissues
and the skeleton. This is achieved by reestablishing normal
insertions of all the nasolabial muscles and correct
anatomical position of the soft tissues recreating the
appearance of the non cleft lip.
• We advocate an advancement/rotation repair of the
unilateral cleft lip incorporating an inferior triangular flap
INTRODUCTION
Clefts of the lip and/or palate are the most common craniofacial
birth anomalies and are among the most common of all birth
anomalies, with prevalence ranging from 1 in 500 to 1 in 2000
births, depending on the population.1 Successful management
of patients born with cleft lip and/or palate requires multidis-
ciplinary, highly specialized team management from birth to
adulthood. An understanding of embryology and anatomy of
the cleft deformity is essential in order to optimize surgical
treatment of cleft lip. The challenges and technique of repairing
unilateral and bilateral cleft lips are outlined.
EMBRYOLOGY OF CLEFT LIP
The primitive craniofacial complex forms during week 4 post-
conception after neural crest tissue migration, early brain vesicle
enlargement, and craniocaudal and lateral trunk folding of the
trilaminar disc. A series of inductive events occur between
the prosencephalon, mesencephalon, and rhombencephalon.
The neural crest tissue that migrates into the craniofacial
complex and pharyngeal arch apparatus helps to form the five
facial prominences, the frontonasal and the bilateral maxillary
and mandibular prominences (Figure 67-1).2 It is the differen-
tiation, growth, and eventual fusion of these prominences that
forms the definitive face.
The upper lip is completed on either side of the globular
prominence (see Figure 67-1) by fusing with the freely project-
ing medial nasal prominences of the frontonasal prominence.3
Such fusion requires critically timed coordination of growth
between the processes, exact spatial localization, and apoptosis
(or further differentiation) of the epithelium that forms the
transient nasal bridge or fin between the two processes.4
The degradation of the underlying nasal fin allows for the
948
addressing the medial shortening and lateral displacement
while restoring normal anatomy, lip length, and symmetry.
• Repair of a bilateral cleft lip is characterized by a huge
diversity of treatment protocols that are often associated
with more long-term issues than unilateral clefts.
• Nasoalveolar molding (NAM) is promising but
objective analysis of long-term outcome has not yet been
reported.
uninterrupted movement of mesenchymal cells between the
medial and lateral components of the upper lip by 8 1 2 weeks
postconception (see Figure 67-1).5
Cleft lip can be caused by:
• Abnormal growth in the direction of the facial
prominences
• Change in position of the nasal placodes6-8
• Hypoplasia or abnormal directional growth of mesenchymal
processes
• Failure of fusion or breakdown of fusion of mesenchymal
processes6,8,9
Disruption of matrix metalloproteinase enzyme activity and
its effect on the medial edge epithelium is an example of a pos-
sible common pathway for the range of genetic and environ-
mental influences that result in cleft palate.10 The severity of the
deformity is related to the amount, timing, and location of the
embryonic interruption.11
CLASSIFICATION OF CLEFT LIP AND PALATE
Cleft lip and/or palate can be divided into two groups
(Figure 67-2):
• Primary palate—lip, alveolus, and hard palate anterior to
incisive foramen (i.e., the premaxilla)
• Secondary palate—hard and soft palate posterior to incisive
foramen
Primary and Secondary Palate
Many different classification systems of varying complexity
have been proposed for cleft lip and palate (see Figure 67-2).
Veau’s 1931 classification, which has four categories, is an
example of a simple system (Figure 67-3)12:
• Group I: Defects of the soft palate only
• Group II: Defects involving the hard palate and soft palate
 CHAPTER 67  Techniques for Cleft Lip Repair 949

A B
FIG 67-1  Development of the facial processes. A, Representation of a 30- to 32-day-old human
embryo showing the development of the facial processes. FNP, Frontal nasal process; LNP,
lateral nasal process; MAN, mandibular process; MAX, maxillary process; MNP, medial nasal
process. B, Representation of an 8 12 -week-old embryo showing the fate of the facial process.

Bilateral 
Right + Left

Nose Median

Right Left Primary palate

Lip

Alveolus
Incisive fossa
A B
Hard palate

Secondary palate
Soft palate

Line of cleft

FIG 67-2  Primary and secondary palate.

• Group III: Defects involving the soft palate to the alveolus,

usually involving the lip
• Group IV: Complete bilateral clefts
Veau’s Classification
Veau’s classification is incomplete, because it makes no
provision for isolated cleft lip or alveolus (see Figure 67-3).
Further cleft lip and palate classifications were described
by Fogh-Andersen in 1942, Kernahan and Stark in 1958, and
Pfeifer in 1971.13-16
Kriens introduced a simple coding system for paraphrasing
cleft lip and palate in 1989.17 This system represents the
anatomical site, the side, and type of cleft (complete, partial,
microform) in a simple alphabetical code: LAHSHAL. This
classification was modified on the recommendation of the
Royal College of Surgeons (United Kingdom) in 2005 by omit-
C D
FIG 67-3  Veau classification. A, Group 1 – defects of the soft
palate only. B, Group 2 – defects involving the hard and soft
palate. C, Group 3 – defects involving the soft palate to the
alveolus, usually involving the lip. D, Group 4 – complete bilat-
eral clefts.
ting one H from the acronym LAHSHAL to become LAHSAL.
The LAHSAL code is based on the striped Y diagrammatic
classification (Figure 67-4).
The relevant parts of the mouth are subdivided into six
parts:
1. Right lip
2. Right alveolus
950 CHAPTER 67  Techniques for Cleft Lip Repair

3. Hard palate
4. Soft palate
5. Left alveolus
6. Left lip
The code is then written as if looking at the patient. The first
character is for the patient’s right lip and the last for the left lip.
Complete clefts are recorded in upper case and partial clefts in
lowercase, and microform clefts are denoted by an asterisk. No
cleft is represented with a dot. This classification system is used
in the United Kingdom because it has the advantage of being
easy to record in medical records and electronically.
Examples of the LAHSAL Cleft Classification
Some examples of the LAHSAL cleft classification are as follows:
• Bilateral complete cleft of lip and palate: A complete bilat-
eral cleft lip and palate is represented by all six capital
letters—LAHSAL.
• Right incomplete cleft lip: A right incomplete cleft lip is
represented by the lowercase letter “l” only. Because it is on
the right, the “l” is written at the beginning—“l….”
• Left complete cleft lip and palate: A left complete cleft lip is
represented by the capital letters HSAL. Because it is on the
left, the HSAL is written at the end—“…HSAL.”
• Left incomplete cleft lip and alveolus: A left incomplete cleft
lip and alveolus is represented by the lowercase letters “a” and
“l” and they are written at the end—“…al.”
• Incomplete hard palate and complete soft palate cleft: An
incomplete cleft of the hard palate is represented by the
lowercase letter “h,” and the complete cleft of the soft palate
is represented with the capital letter “S”—“…hS….”

UNILATERAL CLEFT LIP ANATOMY

Skin Anatomy
The anatomy of the skin of the unilateral cleft lip is character-
ized by shortening of the skin on the medial side of the cleft lip
with lateral displacement of the skin on the lateral side of the
cleft (Figure 67-5). The skin is retracted and displaced and is
associated with sterile mucosa along the cleft margins on both
sides of the cleft. There is vertical soft tissue deficiency on the
medial aspect of the cleft and a discontinuity of skin, muscle,
and oral mucosa on the upper lip on the cleft side. The junction
between the skin and vermilion forms a pale and raised ridge
to a variable degree in continuity with the white roll.

FIG 67-4  LAHSAL cleft classification.
Muscle Anatomy
The upper lip is formed by a series of three interconnected
muscle rings extending from the infraorbital rim and nose
down to the chin (Figure 67-6, A). These nasolabial
muscle rings form part of the fascial envelope in continuity

Lateral Shortening of
displacement of skin of medial
skin on the side with
lateral side vertical soft
tissue
deficiency
Pale raised
ridge
Sterile
mucosa
Sterile
mucosa

White roll

FIG 67-5  Anatomy of skin in unilateral cleft lip.

 CHAPTER 67  Techniques for Cleft Lip Repair 951

A B
FIG 67-6  A, Nasolabial muscle ring in the non-cleft lip. B, Nasolabial muscle ring in the unilateral
cleft lip.

Separation of domes of the alar cartilage

at the nasal tip and retroplacement Deflection of the nasal tip
of the cleft alar cartilage dome toward the non-cleft side
Rotation of septum, columella, and
Kinking of the lateral crus on the cleft side nasal spine away from cleft with
forming obtuse angle with medial crus shorter columella on the cleft side

Dislocation of the caudal portion

of the septum to the non-cleft side
Displacement of alar base in all from the nasal spine
three planes

Larger nares on the cleft side Inferior displacement of the

medial crus within the columella

FIG 67-7  Nasal anatomy of the unilateral cleft lip.

with the superficial musculo-aponeurotic system (SMAS) (see
Figure 67-6, A).
In the unilateral cleft lip and palate, the upper and middle
muscle rings are incomplete (see Figure 67-6, B). All the muscle
groups on the cleft margins of the cleft, which normally insert
onto the anterior nasal spine (ANS), septum, and anterior
surface of the premaxilla, become bunched up at the border of
the cleft. The abnormal muscle function produces characteristic
nasal and mucocutaneous abnormalities, which have to be
addressed at the time of primary lip repair. The unilateral cleft
lip is characterized by discontinuity, disorientation, and mal
insertion of the orbicularis muscle, causing horizontal and ver-
tical lip discrepancy. In a complete cleft lip, the deep fibers of
the orbicularis oris muscle are interrupted by the cleft. In addi-
tion, the superficial component of the orbicularis oris turns
upward, along the margins of the cleft, and it ends beneath the
base of the ala or columella.
Incomplete cleft lip behaves in a similar manner, except
when the cleft is less than two-thirds of the height of the lip. In
this case, the fibers of the muscle run along the margins of the
cleft, then change direction and run horizontally over the top
of the cleft. These muscle fibers are interspersed with connective
tissue.
Some general observations from the perspective of cleft lip
repair are apparent:
• The upper and lower muscle rings converge toward the ANS
and nasal septum.
• The transverse nasalis muscle intermingles with the levator
labii superioris and levator labii superioris alaeque nasi to
form a modiolus that fans out to insert into the nasal sill. It
influences the shape and position of the ala cartilage and the
height of the nasal sill.
• The almost vertical orientation of the external or superficial
part of the orbicularis oris and its connections with the
muscles of the upper ring and with the lower ring through
the modiolus are significant.
Nasal Anatomy
The obvious deformity of nasal form in unilateral cleft lip and/
or palate is due to the incorrect insertion of the transverse
nasalis muscle and displacement of the septum (Figure 67-7).
The muscle in the lateral element is deprived of insertion to the
952 CHAPTER 67  Techniques for Cleft Lip Repair
ANS and pulls the lateral lip element and alar base of the nose
laterally. The alar cartilage is flattened and deformed but is not
hypoplastic. The lateral crus of the lower lateral cartilage is
pulled laterally and lengthened at the expense of the medial crus
thereby flattening the dome. Its inferior border is also rotated
inferiorly forming a web inside the nostril. The anterior nasal
septum and columella are deviated to the medial side. The
anterior part of the greater segment of the maxillofacial complex
is displaced anteriorly due to lack of molding of the nasolabial
muscles.
The anatomical features of the nose in unilateral complete
cleft lip are illustrated in Figure 67-7 and are listed in Box 67-1.
BOX 67-1  Anatomical Features of the
Nose in Unilateral Cleft Lip
Abnormal muscle insertions into nasal spine away from cleft
Defect in primary palate anterior to incisive foramen
Rotation of septum, columella, and nasal spine away from cleft
Separation of domes of the alar cartilage at the nasal tip and kinking of
the lateral crus on the cleft side
Dislocation of lower and upper lateral cartilages on the cleft side
Displacement of alar base in all three planes
Inferior displacement of the medial crus within the columella
Dislocation of the caudal portion of the septum to the non-cleft side
from the nasal spine
Displacement and flattening of the nasal bone on the cleft side
Deflection of the nasal tip toward the non-cleft side
Retroposition of the cleft alar cartilage dome
Obtuse angle between the medial and lateral crura of the lower lateral
cartilage on the cleft side
Absence of the alar-facial groove on the cleft side and attachment of
the ala to the face at an obtuse angle
Larger nares on the cleft side
Shorter columella on the cleft side, positioning the entire columella at
a slant toward the non-cleft side
FIG 67-8  Microform cleft lip.
UNILATERAL INCOMPLETE CLEFT LIP ANATOMY
Microform cleft lip involves partial or total clefting of the upper
lip musculature (Figure 67-8). Incomplete cleft lip involves skin,
muscle, and mucosa, but it may spare the underlying skeletal
structures (Figure 67-9). Complete unilateral cleft lip involves
skin, muscle, mucosa, and underlying skeletal framework.
There are subtle textural differences between the nasal skin
and lip skin in an incomplete cleft lip. During the repair of a
cleft lip, they are separated at their junctions to align nasal skin
with nasal skin and lip skin with lip skin.
Muscle dissections in stillborn babies have shown that the
upper lip muscles in incomplete cleft do not cross the cleft gap
unless the skin bridge is greater than one-third of the height of
the lip.18 Even if orbicularis oris muscle is present in the skin
bridge, the orientation of the fibers is abnormal and the mus-
culature is not functionally correct. Therefore repair of the
incomplete cleft lip requires a full muscle dissection on the
medial and lateral segments to allow for a functional muscle
repair across the cleft.
BILATERAL CLEFT LIP ANATOMY
Skin
The anatomic skin characteristics of bilateral cleft lips are deter-
mined by the degree of completeness of the cleft and its sym-
metry. The prolabial skin in bilateral cleft lip varies in size, is
often retracted, and lacks muscle fibers (Figure 67-10). In addi-
tion, the columella is shortened, and the prolabium appears
attached to the top of the nose in some cases. The size and posi-
tion of the premaxilla varies but it is rotated upward and pro-
truded. In some cases, it can be excluded from the alveolar arch
with a collapse of the lateral elements. The isolated prolabium
is deprived of muscle and normal vermilion and is lined by
Partial or total cleft
of upper lip musculature
 CHAPTER 67  Techniques for Cleft Lip Repair 953

Nasal skin
Absence of functional
muscle in skin bridge
Lip skin

FIG 67-9  Incomplete cleft lip.

Apparent
absence of
columella

Abnormal
Retracted prolabial vermilion
skin lacking continuity of lined by
orbicularis oris muscle fibers sterile
mucosa

Protrusion
and rotation Collapse of
of premaxilla lateral palatal
segments
behind the
premaxilla

FIG 67-10  Skin anatomy of bilateral cleft lip and palate.

sterile mucosa. The prolabium located centrally is devoid of
muscle and consists of skin, vermilion, and oral mucosa.
There is no definitive line of demarcation between the colu-
mella and prolabium. The premaxilla may be situated centrally,
asymmetrically to the right or left, anteriorly, superiorly, or
inferiorly, or a combination of thereof (Figure 67-11).
Muscle
The nasolabial muscle rings are disrupted in complete bilateral
cleft lips, and their abnormal insertions result in lateral dis-
placement of the lateral nasolabial elements. On the lateral
segments, the lip vermillion is turned upward to join the alar
base. This is because the levator alaeque nasi, levator labii supe-
rioris, transverse nasalis, and intrinsic upper lip muscles orbi-
cularis marginalis are oriented upward and inserted into the
alar base and maxilla along the pyriform ring (Figures 67-12,
67-13, and 67-14), resulting in an absence of muscle in the
prolabial segment.
Nose
The nasolabial deformity in bilateral cleft lip and palate is
largely caused by secondary hypoplasia rather than primary
954 CHAPTER 67  Techniques for Cleft Lip Repair

Protrusion and anterior

rotation of the premaxilla

FIG 67-11  Rotation and protrusion of the premaxilla on lateral view.

A B
FIG 67-12  A, Nasolabial muscle ring in the non-cleft lip. B, Nasolabial muscle ring disruption in
a complete bilateral cleft lip.

mesenchymal deficiency.19 The most important feature of the
bilateral cleft is the short columella that is produced by an unop-
posed muscular pull on elements of the lateral cleft in the early
stages of fetal development. The bilateral nasal cleft is seldom
corrected by functional surgery alone, and the appearance of a
repaired bilateral cleft lip is often dominated by the short, teth-
ered appearance of the columella, and a broad nasal tip (Figure
67-15). The lower lateral cartilages are pulled laterally, resulting
in a flattened appearance of the nose. The septum and premax-
illa are attached to the vomer as a thin stalk. Alar domes and
middle crura are splayed, caudally rotated (bucket handle), and
subluxed from their normal anatomic position overlying upper
lateral cartilages. The nasal tip appears large, flat, and bifid,
because both alae are rotated downward and spread apart.
 CHAPTER 67  Techniques for Cleft Lip Repair
PHILOSOPHY OF CLEFT LIP REPAIR
The essential objectives of cleft lip repair are the restoration of
normal function and appearance of the lip and nose. This is
achieved by reestablishing normal insertions of all the nasola-
bial muscles and correct anatomical position of the other soft
tissues, including the mucocutaneous elements. Therefore, an
anatomic and functional balance between the soft tissues and
the skeleton is reestablished.
• Skin: The skin is corrected in both vertical and horizontal
orientation. To restore normal height of both sides of the
cleft relative to the non-cleft side, it is necessary to restore
the normal length of the skin on the cleft side using various
techniques, such as the rotation advancement design (Delaire
and Millard), undulating wavy flaps (Pfeiffer), straight line
design (Rose-Thompson), lower lip Z-plasties/triangular
flaps (Tennison-Randall, Skoog, Trauner, or Malek), the
Absence of muscle in the Lateral displacement and
prolabial segment insertion of nasiolabial
muscles into the alar base
FIG 67-13  Absence of muscle in the prolabial segment.
FIG 67-15  Muscle anatomy in unilateral cleft lip.
955
quadrangular flap (Le Mesurier), or a combination of the
advancement rotation and wavy line techniques (Afroze).20-24
The skin of the lip on the medial element is short as a con-
sequence of the change in normal muscular actions. Careful
reconstruction of the nasolabial muscles allows the overlying
skin to lengthen to the correct lip height.
• Muscle: The fundamental goal of surgery is to achieve ana-
tomic muscular reconstruction, particularly with respect to
anchorage of the complex nasolabial muscles of the cleft side
to the nasal septum and muscles on the non-cleft side (see
Figure 67-15). It is necessary to reconstruct the nasolabial
muscles of the cleft such that the skin margins are not under
FIG 67-14  Nasolabial muscle ring disruption in the bilateral
cleft lip.
Broad, flat and
bifid nasil tip
Short tethered
columella
Caudal rotation of
splayed alar domes
“Thin stalk” -like septal
attachment of premaxilla
to vomer
956 CHAPTER 67  Techniques for Cleft Lip Repair

tension at the moment of skin closure (Figure 67-16). If the
primary nasolabial muscle reconstruction is good, anatomy,
function, skeletal growth, and total facial esthetics can be
excellent.
• Nose: The nasal septum is deviated in unilateral cleft lip.
There are two reasons for this:
• Position of the ANS: It is positioned toward the non-cleft
side and therefore pulls the septum, which is attached to
it toward the non-cleft side.
• Muscle attachments of the medial side: The most nasal
and deep bundles of orbicularis muscle insert into the
mucoperichondrium and anterior nasal septum. There-
fore, they pull the caudal part of the septum toward the
medial side.
Septal deviation causes the upper lateral cartilage to buckle,
depressing the radix, and also causes the lower lateral cartilagi-
nous framework to shift, thereby collapsing the dome on the
lateral side (Figure 67-17).

Aim is to anchor muscles on cleft side to the nasal

Functional reconstruction of muscles with skin margins lying passively
septum and muscles on the non-cleft side

A B
FIG 67-16  A, Functional muscle reconstruction in unilateral cleft lip. B, Muscle in repaired uni-
lateral cleft lip.

Depression of radix due

to buckling of upper
lateral cartilage
Septal deviation to
the medial side

Collapse of dome lower

lateral cartilage on
lateral side

FIG 67-17  Deviation of nasal septum to non-cleft side.

 CHAPTER 67  Techniques for Cleft Lip Repair 957

Septoplasty at the time of lip repair produces a straighter
nasal septum positioned in the facial midline and restores the
patency and natural width of the nostril (Figure 67-18). To
achieve the proper midline position and attitude of the nasal
septum, the surgeon must perform a wide subperichondrial
dissection on both sides of the septum. Once the deviated nasal
septum is repositioned, nostril patency is reestablished on the
cleft side.
The nasal floor is also reconstructed to eliminate the vestibu-
lar oral nasal communication if the palate is involved. A vomer
flap is used when possible to repair the anterior hard palate in
continuity with the floor of nose. There is no evidence to
support the hypothesis that vomer flaps restrict maxillary
growth.25
Alveolar Cleft Segments
The distance between the greater and lesser segments is propor-
tional to the width of the cleft lip. The segments will be approxi-
mated from pressure exerted on them by the repaired cleft lip
molding the anterior element of the greater segment as shown
in the preoperative (Figure 67-19) and postoperative (Figure
67-20) molds of cleft lip repairs.

Septoplasty repositions
the nasal septum

Restoration of patency
and natural width of
the nostril

FIG 67-18  Septoplasty with repositioning of the caudal aspect of the nasal septum.

Preoperative gap
between greater and
lesser segments

FIG 67-19  Gap between greater and lesser segments preoperative cleft lip repair.
958 CHAPTER 67  Techniques for Cleft Lip Repair

Postoperative narrowing of
gap between greater and
lesser segments

FIG 67-20  Reduction of gap between greater and lesser segments postoperative cleft lip repair.

A Incision
B
FIG 67-21  A and B, Raising a vomer flap into the anterior hard palate.

A Exposed bone
B
FIG 67-22  A and B, Insetting a vomer flap into the anterior hard palate.

Anterior Hard Palate
A vomer flap is raised and inset into the cleft margin (Figure
67-21) to close the anterior hard palate at the time of repair of
the cleft lip to establish continuity of nasal floor closure (Figure
67-22). There may be some narrowing of the width of the pos-
terior cleft palate following vomer flap closure.
THE SOUTH WALES CLEFT TEAM PROTOCOL FOR
CLEFT LIP REPAIR: ADVANCEMENT/ROTATION LIP
REPAIR WITH AN INFERIOR TRIANGULAR FLAP
The authors close the cleft lip at 3 months old and the repair
involves the following key steps:
 CHAPTER 67  Techniques for Cleft Lip Repair
1. An advancement/rotation repair of the cleft lip incorporat-
ing an inferior triangular flap addressing the medial shorten-
ing and lateral displacement while restoring normal anatomy,
lip length, and symmetry
2. Achieving a functional muscular repair by restoring the
displaced muscles to their correct anatomical position and
recreating the muscular rings of mid and lower face
3. Using a vomer flap to repair the anterior hard palate in
continuity with the repair of the floor of nose
4. Performing a McComb’s nasal dissection if required to
release the lower lateral cartilage, allowing it to sit in a correct
anatomical position
5. Straightening of the caudal aspect of the nasal septum to
place the septum in its correct central anatomical position
The key surgical steps in the authors’ surgical protocol are as
follows:
1. Right complete cleft lip: Identification of key surgical land-
marks show on an illustration and clinical photograph
(Figure 67-23).
2. The skin markings include the following key landmarks
(Figure 67-24):
• Cupid’s bow markings: Non-cleft side peak, trough and
peak on the cleft side (a point on the cleft side equidistant
from the trough of the cupid’s bow)
• First change in the appearance of white roll on the lateral
element: The point of first change of the white roll and
where the white roll and vermilion start to converge
• Base of columella: Remember it is rotated
• Alar base: The inferior lateral point
3. Curved incision along the short medial element (Figure
67-25): The aim is to place the scar in the line of the natural
philtral ridge. The medial side of the philtrum must be
lengthened to match the non-cleft length. The incision does
not extend along the base of columella at its superior aspect.
The incision extends from the base of columella on the cleft
A B
FIG 67-23  Left unilateral cleft lip. A, Diagram. B, Clinical
illustration.
Base of columella
Peak of cupid’s bow on medial
side—equidistant from the trough
compared with the non-cleft side
Peak and trough of
cupid’s bow
FIG 67-24  Skin markings on complete left unilateral cleft lip.
959
side to the cleft side peak of the cupid’s bow curving parallel
to and just above white line. It is curved medially and turns
across the vermilion through 90 degrees at the cupid’s bow
peak and extends just past the wet-dry mucosal junction.
4. The incision on the lateral side extends from the alar base
along the junction of the nasal and lip skin to meet the
mucosa at 90 degrees (Figure 67-26). The incision then
extends from this point along the white roll parallel to the
skin/mucosal junction to the meet the upper point of the
lateral triangular flap.
5. An inferior triangular flap is incorporated along the incision
in lateral element and inset into a backcut in the medial
element to lengthen the deficient medial element (Figure
67-27). The triangle and the backcut must be the same
height above the white roll. The addition of an inferior tri-
angle to the advancement/rotation repair of a cleft lip allows
full restoration of length without the overextension of the
medial incision under the base of columella. The lip length
must not be shorter than normal side at end of surgery.
6. Advancement of the lateral side to align with the rotated
short medial element (Figure 67-28).
7. The intranasal incisions are illustrated in Figure 67-29.
The incision on the medial element extends at a tangent
to the curved incision, extending into the floor of the nose along
the nasal/oral mucosal junction. It will connect to the vomer
flap, and the raised flap will form the medial floor of the nose.
The incision on the lateral element is a continuation of the
lateral element incision into the nose parallel to the junction of
the skin-mucosal junction. This incision extends to the alveolus
and sits just below the inferior turbinate.
1. Outline of sterile mucosa: The incisons are extended across
the white roll medially and laterallly at 90 degrees to the
white roll. They extend though the wet–dry junction and
then up into the nose. The mucosa outlined is the sterile
mucosa.
No extension across
base of columella
Incision extends across white roll
at 90 to cupid’s bow peak
Extends just past the wet/dry junction
FIG 67-25  Curved incision on medial element.
Alar base
First change in
the white roll on
lateral element
960 CHAPTER 67  Techniques for Cleft Lip Repair
Short philtral length on
the medial element
Normal philtral length on
the non-cleft side
FIG 67-26  Lateral skin incision.
Inferior triangle placed just above the white
roll on the lateral side and inset into the
backcut on the medial side to lengthen the
skin deficiency on the medial side
FIG 67-27  Inferior triangle and backcut.
Tangential curve extending
into the floor of the nose along
the nasal/oral mucosal junction
FIG 67-29  Nasal incisions.
2. Advancement rotation skin markings with an inferior tri-
angle (Figure 67-30): The vermilion border is tattooed with
ink; these points act as landmarks to allow accurate recon-
struction of the white roll. Local anesthetic is infiltrated and
marking incised. The sterile mucosa is excised, and the
muscle edges are identified along both sides of the cleft
margin.
3. Muscle dissection: The muscle is dissected on both sides of
the cleft to separate the muscle from the mucosa and dermal
layers. On the medial side, dissection of the muscle is
carried out to relieve the abnormal attachments from ANS
and the columella allowing lengthening and rotation of the
skin deficiency on the medial element (Figure 67-31). On
the lateral side, muscle dissection is done to identify and
mobilize the head of the transverse nasalis and the length
of orbicularis (Figure 67-32).
Nasal skin
Incision that separates nasal
skin from the lip skin
Lip skin
Incision extending from the
junction of lip/nasal skin
with mucosa along the white
roll to the point of first change
in the white roll
Advancement of the lateral element
to upper landmark to base of columella
mark on the medial segment
Advancement of lateral element triangular
flap to the back cut on the medial segment
FIG 67-28  Advancement and rotation.
Continuation of the lateral
element incision into the nose
parallel to the junction of the
skin-mucosal junction
4. Subperiosteal dissection: This is performed if the transverse
nasalis muscle will not reach the ANS. After the muscle
dissection is done, an incision is made in the buccal sulcus
up to the nasal margin of the cleft. A wide subperiosteal
dissection is done from the vestibule on the cleft side over
the piriform rim, nasal bone, and infraorbital and malar
regions to lift the facial mask, taking care to protect the
infraorbital nerve (Figure 67-33).
5. McComb nasal dissection26: This should be performed as
required if the lower lateral cartilage will not sit in the
correct position when the nasal muscle is approximated.
Access is gained to the lower lateral cartilages through a
medial approach, allowing blunt dissection of the cartilage
from the overlying skin/nasal mucosa. The plain of dissec-
tion is subdermal and submucosal. The lower lateral carti-
lage can also be approached from the lateral aspect if
 CHAPTER 67  Techniques for Cleft Lip Repair 961

Sterile
Sterile
mucosa on
mucosa on
lateral side
medial side

FIG 67-30  Sterile mucosa on medial and lateral elements.

Muscle dissection from

ANS and deviation of base
of septum

FIG 67-31  Dissection of muscle on the medial side. ANS, Anterior nasal spine.

required, but this isn’t commonly performed (Figure
67-34). The McComb dissection reduces the buckling effect
of the lateral crus of the lower lateral cartilage, allowing it
to sit in a more natural position.
6. Septoplasty: Correction of the caudal aspect to the deviated
nasal septum provides stability and exact positioning of the
previously lifted alar crus of the cleft side and nasal tip. This
allows the nose to grow in a balanced way with equal muscu-
lar force being exerted on both sides. The caudal aspect of the
nasal septum is then carefully isolated and freed through the
same cleft incision by splitting and raising the perichon-
drium on both sides (Figure 67-35). The septum is detached
from its attachment to the nasal spine and maxillary crest,
straightened and repositioned centrally (Figure 67-36).
7. Nasal floor reconstruction: The nasal floor is reconstructed
by suturing the hair-bearing nasal mucosa on both sides,
posteriorly closing the lateral nasal floor to the vomer flap
(Figure 67-37).
8. Suturing of transverse nasalis to ANS/septum: This is
done to secure the position of the base of the septum
(Figure 67-38).
9. Natural approximation of orbicularis oris: The orbicularis
is approximated and sutured to a natural position main-
taining the muscle length (Figure 67-39).
962 CHAPTER 67  Techniques for Cleft Lip Repair

Muscle dissection
identifying head of
transverse nasalis

FIG 67-32  Dissection of muscle on the lateral side.

Infraorbital nerve foramen

Subperiosteal dissection
extending from piriform rim
to malar prominence

FIG 67-33  Subperiosteal dissection on lateral side.

Nasal cartilage

Medial blunt
dissection

FIG 67-34  McComb nasal dissection.

 CHAPTER 67  Techniques for Cleft Lip Repair 963

Exposure of the
caudal aspect of
the deviated nasal
septum

FIG 67-35  Exposure of the deviated caudal aspect of the nasal septum.

Detachment of septum from

ANS and straightening of
septum

FIG 67-36  Detachment and straightening of caudal aspect of nasal septum. ANS, Anterior nasal
spine.
964 CHAPTER 67  Techniques for Cleft Lip Repair
FIG 67-37  Reconstruction of nasal floor.
FIG 67-38  Suturing of transverse nasalis to anterior nasal spine (ANS)/septum.
10. Skin closure: Tension-free skin closure is performed (Figure
67-40). This is made possible by the subperiosteal dissec-
tion, radical mobilization, and suturing of the transverse
nasalis and orbicularis muscles.
COMMON TECHNIQUES OF CLEFT LIP REPAIR
Millard Cleft Lip Repair
Flap Design
The Millard cleft lip repair is based on a rotation flap on the
medial cleft side coupled with an advancement flap on the cleft
Reconstruction of
floor of nose
Suturing of
transverse
nasalis to
ANS/septum
lateral side.27 The incision is then bowed in a curvilinear fashion
near the base of the columella crossing the philtrum toward the
far lateral extent of the columellar base (Figure 67-41).28 In one
form or another, it is the most widely practiced method today.
The rotation advancement technique relies on a “cut as you
go” strategy that allows continuous modifications during the
design and execution of the repair. It does not adhere to strict
geometrical principles or measurements.
However, it may leave a scar crossing the midline at the base
of the columella and cause shortening of the lip on the cleft side
with resultant vermilion notching and whistle deformity.
 CHAPTER 67  Techniques for Cleft Lip Repair 965

Natural
approximation of
orbicularis oris

FIG 67-39  Functional repair of orbicularis oris.

FIG 67-40  Tension free closure of skin.

Delaire Cleft Lip Repair Pfeiffer Cleft Lip Repair

The Delaire cleft lip technique incorporates a curvilinear inci-
sion that extends up and parallels the medial cleft margin but
stops near the medial edge of the base of the columella.29 The
lateral lip element advancement incision curves outward and
then medially as it extends superiorly before it again extends to
the alar base (Figure 67-42).30
Delaire does not incorporate an inferior triangle into
his cleft lip repair, which limits the extra length that can
be gained. A Delaire cleft lip repair does not include a
vomer flap.
Flap Design
Pfeifer described a wavy-line repair that allowed downward
rotation as the curves were approximated into a straight line.31
The two curves are brought together such that the highest and
lowest points of one curve are approximated with the corre-
sponding highest and lowest points of the other, thus creating
a straight line (Figure 67-43).
The Pfeiffer repair achieves good vertical length soft tissue
reconstruction; but in some cases, this can be at the expense of
soft tissue reconstruction in the horizontal dimension.
966 CHAPTER 67  Techniques for Cleft Lip Repair
FIG 67-41  Millard repair.
FIG 67-42  Delaire repair.
FIG 67-43  Pfeiffer repair.
Afroze Cleft Lip Repair
Flap Design
The Afroze incision is a combination of two incisions—the
Millard incision on the medial cleft side and the Pfeiffer incision
on the cleft side (Figure 67-44).32 The flap is designed so that
the Millard flap on the cleft side rotates downward, and the peak
of the distal curve on the Pfeiffer flap is positioned in the tri-
angular defect formed by the downward movement of the
Millard flap.
The lip scar does not lie along the philtrum; this is the only
disadvantage of this technique. However, the scar heals excep-
tionally well because the wound is closed under no tension
whatsoever.
FIG 67-44  Afroze repair.
FIG 67-45  Tennison repair.
Tennison Cleft Lip Repair
Flap Design
The triangular flap repair was initially described in 1952 by
Tennison.33 Tennison’s technique made use of an inferior
backcut that begins not far above the cleft-side peak of the
cupid’s bow of the medial lip element and angled superolater-
ally. Precisely measured triangle flaps allow vertical lengthening
of the medial lip element while enabling lengthening of what is
often an otherwise short transverse lateral lip element without
compromising the ideal basal position of the philtral column
incision (Figure 67-45).34
The main disadvantage of the triangular flap repair tech-
nique is that the philtrum on the cleft side is violated by the
triangular flap. Some authors believe this leaves a more notice-
able scar. Another potential disadvantage is the difficulty in
modifying the repair or performing secondary revision at a later
stage due to the zigzag scars.
Fisher Cleft Lip Repair
Flap Design
The repair allows for a repair line that ascends the lip at the
seams of anatomical subunits. Applying the principle of ana-
tomic subunits to cleft lip repair, the “ideal line of repair” should
be one that ascends the lip from the cleft-side peak of cupid’s
bow to the base of the nose along a line exactly mirroring
the non–cleft-side philtral column (Figure 67-46).35,36 These
maneuvers help preserve natural subunit boundaries, allowing
for rotation and medial lip lengthening at the expense of nar-
rowing the philtrum to a degree.
 CHAPTER 67  Techniques for Cleft Lip Repair 967

Fisher often adds a small inferior triangle just above the
cutaneous roll for additional rotation and feels that this accen-
tuates the pout of the lip. Although this technique is included
in the category of rotation/advancement repairs, it is clearly a
hybrid of multiple principles, including triangle-flap techniques
FIG 67-46  Fisher repair.
and use of geometric and curvilinear incisions to approach a
vertically oriented closure.
REPAIR OF THE INCOMPLETE CLEFT LIP
The repair of the incomplete cleft lip follows the same principles
as outlined for the repair of the complete cleft lip. The incision
is modified to divide the nasal skin from the lip skin in a line
along the base of the nasal sill (Figure 67-47). The texture of
the nasal skin is different from the texture of the skin of the lip,
and the incision line is placed between the junction of both skin
types. The texture of the skin that is excised is abnormal due to
the lack of underlying muscle insertion. A small wedge excision
into the nasal sill may be used to prevent a prominence of scar
tissue from developing in this area. The authors do not include
this extension into the nasal sill, because it may lead to nostril
narrowing and flattening of the nasal sill. If a tissue prominence
should develop, it can be easily treated with a wedge excision at
a later date.

Skin of the floor

of the nose

Lip skin

Sterile mucosa
to be excised

C
B

FIG 67-47  A, An incomplete left side cleft lip. B and C, Preoperative skin markings for an incom-
plete left side cleft lip repair.
968 CHAPTER 67  Techniques for Cleft Lip Repair
FIG 67-48  Postoperative result for the repair of an incomplete
left side cleft lip.
The postoperative result for an incomplete cleft lip repair is
illustrated in Figure 67-48.
SURGICAL REPAIR OF THE BILATERAL CLEFT LIP
The incidence of bilateral cleft lip (Figure 67-49) and palate is
much lower than that of unilateral cleft lip and palate, and it
makes up less than 10% of all cleft deformities. Of all the dif-
ferent types of cleft deformity, the complete bilateral cleft lip
and palate presents the greatest challenge to the cleft team.
There is very little conformity in the technique and timing of
repair of bilateral cleft lip in the United Kingdom. Repair of a
bilateral cleft lip is characterized by a huge diversity of treat-
ment protocols that are often associated with more long-term
issues than unilateral clefts.
The key principles of repair of the bilateral cleft lip that are
followed are the same as for the unilateral cleft lip. Advance-
ment of the displaced lateral element and the need to regain
length in the short medial element are the same in bilateral as
in unilateral cleft lips (Figures 67-50 and 67-51).
The prolabial skin is raised exposing to allow functional
reconstruction of the muscles across the premaxilla
(Figure 67-52).
Muscle reconstruction is the same as in unilateral cleft lips,
except the two halves of orbicularis and transverse nasalis
muscles are sutured together under the prolabium and trans-
verse nasalis fixed to the ANS (Figures 67-53 and 67-54).
The final closure of the bilateral cleft lip is illustrated in
Figure 67-55. The functional repair of the muscle across the
prolabium retracts the protruding premaxilla back into align-
ment with the lesser segments provided that there hasn’t been
transverse collapse of the lesser segments. The tip of the nose is
flat and depressed, but this is addressed at secondary rhino-
plasty, which is ideally performed when the patient has finished
growing (i.e., in their late teens).
Although the surgical principles of repair of bilateral cleft lip
are similar to those applied to the management of unilateral
FIG 67-49  Asymmetric bilateral cleft lip and palate—incomplete
on the right side and complete on the left side.
cleft lip, this small caseload could be considered suboptimal for
a condition that presents the following unique set of technical
problems:
• Prolabial mucosa: The isolated prolabium, which is deprived
of muscle and normal vermilion, protrudes anteriorly and is
rotated upward. Its dimensions are reduced by secondary
hypoplasia and the frequent absence of lateral incisors. Some
surgeons advocate partial retention of the prolabial mucosa
to recreate a cupid’s bow. The authors do not retain the
prolabial mucosa, because its long-term appearance can be
dry and abnormal if retained. The authors prefer to recreate
the central white roll as a scar line between prolabial skin
and mucosa.
• Nasal deformity: The bilateral nasal cleft is seldom corrected
by functional surgery alone, and the appearance of a repaired
bilateral cleft lip is often dominated by the short, tethered
appearance of the columella and broad nasal tip. An under-
standing of the true nature of the nasal deformity in bilateral
cleft lip has gradually emerged with the simple observation
that the “columella is in the nose.”37-39 Some surgeons
perform primary repair on the nose to retrieve the columella
from the nose and restore the prominence of the nasal tip at
an early age. However, the authors’ preferred protocol is to
avoid primary nasal surgery, because it produces scarring
and fibrosis that may result in unfavorable growth and makes
a secondary rhinoplasty procedure more difficult. Instead,
the authors perform nasal surgery at a preschool age if the
nasal deformity is significant or more ideally in the late teens
at the end of growth. The timing of this is decided by the
parents’ wishes.
• Asynchronous repair: In very severe forms of bilateral cleft
lip, the cleft may be repaired one side at a time (i.e., a one
side first approach). Alternatively, a lip adhesion may be
performed, whereas repair of the muscles is usually com-
pleted at the second stage. Bilateral lip adhesion helps to
reposition the protrusive premaxilla, which enables a later
 CHAPTER 67  Techniques for Cleft Lip Repair 969

Rotation of the medial elements

Nasal skin

Advancement of the
Lip skin lateral elements

Sterile mucosa for excision

along the prolabium
FIG 67-50  Skin markings for repair of a bilateral cleft lip.

FIG 67-52  Excision of sterile mucosa to expose muscles.

FIG 67-51  Skin markings for repair of an asymmetric bilateral
cleft lip.

Suture skin of
floor of nose

Suture through
transverse nasalis

FIG 67-53  Functional reconstruction of transverse nasalis to anterior nasal spine.

970 CHAPTER 67  Techniques for Cleft Lip Repair
FIG 67-54  Functional reconstruction of orbicularis oris muscle repair under the prolabium.
FIG 67-55  Repaired bilateral cleft lip.
definitive repair. This inevitably delays any attempt at syn-
chronous repair of the lip and nose, and there is no evidence
that it improves long-term outcome. The authors’ preferred
method of repair of bilateral cleft lip is a synchronous repair
at 3 to 4 months of age, but they recognize that occasionally
in very wide clefts it may not be technically possible to repair
the muscles completely.
• Pre-surgical orthopedics: Formal surgical repair is often
preceded by pre-surgical orthopedics to retroposition the
premaxilla and enable a tension-free repair of the lip.40 Pre-
surgical orthopedics may be of benefit in the surgical repair
of bilateral cleft lip by helping achieve complete reconstruc-
tion of the muscles across a severe cleft with a protuberant
premaxilla and by lengthening the columella. Although there
is no doubt that it facilitates the repair and is still widely
used, there is no evidence that it improves outcome.41
• Nasoalveolar molding (NAM): This is a form of pre-surgical
orthopedics that expands the columella and repositions the
premaxilla. Columellar lengthening allows the cartilages of
the nasal tip to be reshaped.42-44 Early studies have shown
that NAM does this effectively before operation. Although
early results with preoperative NAM are promising, objective
analysis of long-term outcome has not yet been reported. It
Reconstruction of both
halves of the orbicularis oris
across the premaxilla
is technically demanding for both the orthodontist and the
patient’s carers, and it would benefit from being submitted
to a randomized controlled trial before being universally
adopted as a useful adjunct to the already considerable
burden of care suffered by patients with bilateral clefts. The
use of NAM as an adjunct to primary repair of the lip and
nose has been a recent development that may help improve
nasal outcome.
PITFALLS
• Highly specialized surgery is necessary in the early months of life to
maximize function of the face and oro-pharynx. Deficiencies of facial
and dental development, speech and hearing remain frustratingly
common and may be accompanied by psycho-social issues.
• Evidence for and against the use of the vomer flap is conflicting its
use serves to narrow the hard palate as it heals by secondary inten-
tion. However, avoiding its use would cause less scarring and leave
the alveolus in pristine condition for bone grafting. Ultimately this
might lead to better facial growth.
• Repairing the soft palate at the time of lip repair also encourages the
cleft in the hard palate to narrow due to muscular action. However,
this may increase the risk of a fistula developing at the hard/soft
palate junction.
 CHAPTER 67  Techniques for Cleft Lip Repair
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